Assessing Children as an Orthoptist

Assessing children will be a big part of your day as an Orthoptist. This can be quite daunting particularly when you are first starting out. We want to help you overcome this quicker! In this post you will find a few tips and tricks to overcome some common hurdles we face when assessing paediatric patients.

1. Build Rapport Before You Begin

How you begin can make all the difference between an open and receptive child, and a shy and uncooperative one. Children are more likely to cooperate if they feel comfortable around you. Before jumping into your assessment, have a small conversation with them - ask them how old they are? What year they are in? What their favourite subject at school is? You could also start a conversation around a toy they might have brought in with them, or a character on their t-shirt. Tailor your conversation to the child, and make note of what they say. If a child is very shy, ease them into the conversation by talking through their parents. Use the parents to help you make the child feel more at ease. 

2. Be Playful, Not Pushy

Orthoptic testing often feels like a game to children, and that’s a good thing! Use this to your advantage by making the assessment as fun and engaging as possible. Turn vision tests into a challenge. Use interesting and fun fixation targets. Use praise liberally. If a child is struggling to engage, pushing harder can make things worse. Know when to take a short break and switch to another test.

3. Know Your Tools (and Have Spares!)

Every orthoptist has their go-to paediatric kit. The key to a successful kit is multiple fun fixation targets (lights, spinning toys, finger puppets). Having a variety of tools keeps things interesting and gives you options if a child refuses to engage with one method. Keep your toys very accessible, in an open pencil case for example, because you may not have a lot of time to dig for them.

4. Observe Before You Test

Before you even start testing the child, take a few seconds to observe the child. Watch how they fixate on things, how they move their eyes, and whether there’s any obvious head posture or squint. This can give you valuable clues before formal testing even begins, especially if the child becomes uncooperative later on. Best time to do this is during the case history - the child thinks you aren’t paying attention to them and is more likely to be in their natural state. 

5. Adapt to the Child’s Age and Ability

Your approach should always match the child’s developmental level:

Under 2s: Use preferential looking tests (e.g., Cardiff cards), fix-and-follow techniques, and toys to assess interest and tracking.

Ages 2–5: Picture-based visual acuity charts such as the Kay Pictures is the most ideal. Keep instructions simple and make the assessment gamelike.

School-aged children: LogMAR tests are the most appropriate. Children tend to be more talkative, so ask lots of questions to keep them engaged.

But always tailor your test to the child - some shy school aged children may not cooperate with a letters test but may happily match Kay Pictures for you. And some preschool children may already know their letters, so it’s always best to ask to get the best possible results.

6. Involve the Parents (Strategically)

Parents can be a great help, especially with very young children. They can hold the child, reinforce instructions, or encourage cooperation. However, be mindful: sometimes parental anxiety can frighten the child and make them go into a shell. If needed, gently ask the parent to step back or stay silent during specific parts of the exam. And watch out for any parents secretly trying to feed their child the answers! 

7. Be Flexible with Your Sequence

You don’t have to stick to the traditional order of testing. You do not have to always start with a vision test. If a child is quite shy and may retreat if their eyes are occluded - start with a cover test instead. This will help ease them into the examination and will give you more results in the long run. The goal of your assessment is to gather as much clinically useful information as possible, no matter the order.

8. Don’t Aim for Perfection, Aim for Progress

It’s unlikely you’ll get every test done perfectly, especially with younger children or children with developmental delays. That’s okay. Focus on gathering enough information to form a clinical impression and plan follow-up care. Always document clearly what was attempted, what was achieved, and why any tests were incomplete. This gives the next clinician a good basis to begin their examination next time.

9. Use Praise and Positive Reinforcement

Remember to always let the child know they’re doing great—even if they’re only halfway through the test. Praise effort more than results. Especially if they are struggling, a child may retreat if they feel that they are not doing the tests correctly. Use stickers, stamps and verbal encouragement! Remember to always keep smiling as well. Children can read facial expressions and may become quiet if they think you think they aren’t doing well.

10. Reflect and Learn from Each Case

Every child teaches you something. Reflect after your assessments—what worked well? What could have gone better? Over time, you’ll build a strong toolkit of strategies for managing a wide range of paediatric behaviours.

Testing children is as much about creativity and patience as it is about clinical skill. The more experience you gain, the more intuitive it becomes. Remember: every smile, giggle, and eye movement you capture brings you closer to understanding and helping your patient.

Keep learning, keep adapting—and don’t forget to have a fun!